Imagine what Nightingale might have achieved with an EHR

We are honored this week to have 4 guest authors and guest hosts for the next HCLDR:

Together they are bringing attention to and honoring nurses. Tuesday May 12, 2020 is the 200th anniversary of Florence Nightingale’s birthday. Next week is also Nursing Week. We are truly honored to have these four nurses lead our next discussion.

Please join them on Tuesday May 12th at 8:30pm ET (for your local time click here) for a special Nursing Edition of HCLDR.


Diagram of the Causes of Mortality in the Army of the East’ now known as the Rose Diagram was Nightingale’s way of explaining complex statistics



May 12, 2020 marks the 200th anniversary of the birth of Florence Nightingale.  Annually this day is recognized as International Nurses Day by countries around the world.  Nightingale came to prominence while serving as a manager and trainer of nurses caring for soldiers during the Crimean War.  She gave nursing a favourable reputation and became known as the “The Lady with the Lamp” making rounds of wounded soldiers at night[i]. Florence Nightingale is considered as a pioneer in the use of infographics[ii] The ‘Diagram of the Causes of Mortality in the Army of the East’ now known as the Rose Diagram was Nightingale’s way of explaining complex statistics to inform care[iii].

In 1863, Nightingale wrote that “In attempting to arrive at the truth, I have applied everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any purpose of comparison…”[iv].  Two hundred years later, nurses and other clinicians are still attempting to find the information that they need to support clinical decision-making.

Currently many gaps exist in what is measured in healthcare, with much of the focus on administrative data rather than data that can support clinicians in improving the quality of care[v]. With increased pressure on healthcare organizations to improve clinical quality and efficiency, there is an opportunity for organizations to realize the benefits of electronic health records by standardizing clinical information[vi].  By virtue of nurses being the largest constituency of health professionals in Canada as in other countries, they are the predominant contributors and users of clinical data across the healthcare system. While there has been progress in different areas to identify, define, and standardize clinical data, these data are neither consistently collected nor widely integrated into EHRs. Furthermore, these data are not always captured within administrative systems nor abstracted into key data repositories.

There is often a lack of understanding among healthcare leaders of the value of standardized clinical data both within individual organizations and across care settings. While significant EHR investments have been made little effort has been made to unify approaches to online clinical documentation. Regardless of system vendor, the opportunity to adopt standardized models, tools, and measures is being supplanted by every healthcare organization adopting their own design. Ironically, this is one of the greatest advantages to be to be derived from the use of EHRs, yet has not been addressed within nursing or other health professions.

EHRs contain significant amounts of patient data that can be utilized to support clinical care, patient safety and quality improvement, health system policy and research – see Figure 1.

Figure 1[vii]

At the clinician level the use of standardized tools and measures allow for providing clinicians with individual or unit based scorecards and reports to facilitate examining the impact of their practice on health outcomes such as pain, functional status etc. In addition this information can support unit and organizational level quality improvement initiatives. At the organizational in addition to supporting quality reporting these data can be linked with administrative data to support health human resource planning as well as reporting to the public on the quality of care within the organization.  Furthermore standardized data can inform health policy and health system research through the provision of timely data that is comparable.

If investments in EHRs are to be fully realized, they need to provide patient-centred information that is of value to people within the healthcare system.  Currently clinical data are assessed using various measures within different sectors of healthcare and they are therefore unable to provide a picture of the overall quality of performance for a specific clinician or organization, or for the patient and can’t be compared across the healthcare system. The assessment and collection of clinical information using standardized tools and measures will support the sharing of information between and among healthcare sectors and healthcare providers for improved planning for appropriate care.  Furthermore, as patient’s access to their healthcare records increases it will be important that they see that clinicians are using standardized tools so patients can become active participants in managing their health and monitoring their progress on items such as functional status, symptoms etc.

Brennan and Bakken argue that nursing needs big data and data science to inform new knowledge for nursing[viii]. This is true for all clinicians and clinical data standards are foundational to advancing this agenda in healthcare. Furthermore the use of big data can make real the promise of a Learning Health System. The use of big data can make real the promise of a Learning Health System[ix].

Join the next HCLDR Tweetchat on Tuesday May 12th at 8:30pm ET (for your local time click here) where we will be discussing the following topics:

  • T1 Is comparable sharable clinical data available for use by nurses and other healthcare providers?
  • T2 What are the limitations of currently available clinical data?
  • T3 Given the current pandemic, what might have been the value of more timely practice-based information for clinicians and patients/families?
  • T4 What strategies might be employed to accelerate the adoption of clinical data standards more broadly so we are better prepared for the future?


[i] Shetty, A.P. (2016) Florence Nightingale: The queen of nurses. Medical History, (1), 144-148. Retrieved on February 26, 2020 from

[ii] McDonald, L. (2001). Florence Nightingale and the early origins of evidence-based nursing.  Evidence-based nursing, 68(4).  Retrieved on February 26, 2020 from

[iii] O’Connor, S., Waite, M., Duce, D., O’Donnell, A., & Ronquillo, C. (2020).  Data visualization in health care: The Florence effect. Retrieved on March 30, 2020 from

[iv] Nightingale, F. (1863). Notes on Hospitals. London: Longman, Green, Longman, Roberts, Green.

[v] Veillard, J., O. Fekri, I. Dhalla and N. Klazinga. 2015. Measuring Outcomes in the Canadian Health Sector: Driving Better Value from Healthcare. Retrieved February 24, 2020.

[vi] Rhoads, J. and L. Ferrara. 2012. Transforming Healthcare through Better Use of Data. Electronic Healthcare 11(1): e25–e31.

[vii] Nagle, L.M., & White, P. (2015). Towards a Pan Canadian Strategy for Nursing Data Standards.  Unpublished white paper.

[viii] Brennan, PF., & Bakken, S. (2015). Nursing Needs Big Data and Big Data Needs Nursing. Journal of Nursing Scholarship, 47:5, 477–484.

[ix] Menear, M., Blanchette, M., Demers-Payette, O. et al. A framework for value-creating learning health systems. Health Res Policy Sys 17, 79 (2019). Retrieved March 15, 2020 from


Peggy White, RN, BA, MN is the Project Director for C-HOBIC and the co-lead of the National Nursing Data Standards Initiative.

Tracie Risling, RN, BA, BSN, MN, PhD is an Associate Professor, University of Saskatchewan and the President Elect of the Canadian Nursing Informatics Association.

Lynn Nagle PhD, RN, FAAN is the Director of Digital Health and Virtual Learning, University of New Brunswick, Fredericton, Adjunct Professor, Lawrence S. Bloomberg, Faculty of Nursing, University of Toronto and Western University.  She is the founding President of the Canadian Nursing Informatics Association.

Glynda Rees, RN, BSN, MN is Faculty at British Columba Institute of Technology, and an Affiliate Professor at the University of British Columbia. She is the President of the Canadian Nursing Informatics Association.

Image Credit

By FormerBBC – Own work, CC BY-SA 4.0,

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